Psychotherapies, in general, are developed in direct relation to and, often, as a result of specific personality theories, so, when looking at the nature of any particular therapy it is appropriate to do so in conjunction with the personality theory from which that psychotherapy was developed. Psychoanalysis and Psychodynamic therapies were developed as a result of Sigmund Freud’s (1856 – 1939) theory of personality development, which he formulated, during the 1880’s, after working with Charcot in Paris.
He began to speculate about the nature of the illnesses suffered by some patients which appeared to him not to have a biological source, this led to his theories of the unconscious. His analysis of himself drew him to the conclusion that many of the problems suffered by patients with ‘neurotic’ or ‘hysteria’ based mental disorders could be helped with this type of analysis and psychoanalysis was ‘born’.
Behaviour therapy, in contrast, was developed less from a personality theory and more from the ideas of learning theorists and the theories of behaviourist psychologist’s, such as Watson (1878 – 1958) and Skinner (1904 – 1990). Watson, an animal psychologist, advocated experimental psychology which concentrated on behaviour rather than motivations and this led to a revolution in how many psychologist’s were to view personality development.
Pavlov’s (1849 – 1936) experiments into the conditioned reflexes of dog’s was, years later, to be a basis for Joseph Wolpe’s (b. 1915) behaviour therapy. Within personality theory there are two approaches, one being that personality development and any resulting traits are universal and common to all human beings, this is called a nomothetic approach and to a great degree both psychodynamic and behavioural therapies fall into this category.
Freud believed that given certain situations the majority of individuals will develop in a particular way, and behaviour therapist tend toward the idea that since conditioning is the basis for the formulation of behaviour (and indirectly personality) given certain conditions all individuals will develop in a specific direction. The contrasting approach is that each individual is unique, no two reacting or developing in the same way within situational factors, this is an idiographic approach and an example of this would be Carl Roger’s Humanistic therapies.
A Behaviour therapist tends to take a directive approach, during therapy sessions, which means the therapist makes comment on the process of change, giving their informed opinion about the problems which may need to be addressed by the ‘patient’, therapists taking this approach may also provide work and ideas for the client to pursue at home. Directive therapies tend to have procedures and timetables, for instance behaviour therapy using systematic desensitising will tend to be conducted over a set period of sessions, the client will be expected to have reached a certain ‘point’ in recovery by a certain session.
Non-directive therapy, of which psychoanalysis is an example, takes the form of allowing the client to draw their own conclusions about what is being discussed. The analyst in non-directive therapies takes a more passive role and because of the non-directive nature of the therapy the client is not expected to ‘recover’ within a set timespan. One of the many criticisms of Freudian psychoanalysis is that a client can be ‘in therapy’ for many years and still not be ‘cured’, this may be as a result of the non-directive therapeutic process.
Freud’s view of psychological disorder is that any neurotic symptoms are a result of conflicts within the unconscious. According to Freud the personality has three ‘parts’ the Id which is an instinct based energy source, and is the primary source of human needs, such as a need for food, comfort, sexual pleasure etc. The Ego is a kind of ‘executive in charge’ of the personality and attempts to control the other parts and the Superego, is a ‘higher’ state, which, if moral development has not been blocked, will control such aspects as morality and conscience.
Freud believed that conflicts from the Id and the Superego with the Ego can cause anxiety which, through the processes of defence mechanisms, can result in neurotic disorders, such as obsessions, phobias and hysterical symptoms. For example, an individual with a stutter may be repressing their natural aggressive urges, or someone with a fear of snakes may be repressing sexual anxieties. The purpose of psychoanalysis is to make conscious those unconscious conflicts which cause the patients distress, Freud explained it thus; “……..
The ego has been weakened by the internal conflict……. The analytic physician and the weakened ego of the patient, basing themselves upon the real external world, are to combine against the enemies the instinctual demands of the id, and the moral demands of the superego….. The patient’s sick ego promises us the most candour, promises to put at our disposal all of the material which his self-perception provides ; we, on the other hand assure him of the strictest discretion and put at his service our experience in interpreting material that has been influenced by the unconscious.
Our knowledge shall compensate for his ignorance and shall give his ego once more mastery over lost provinces of his mental life. This pact constitutes the analytic situation “. The process of transference is used to aid the patient’s exploration of their unconscious conflicts, this involves the analyst becoming the object of those repressed feelings. For instance a patient with unresolved conflicts about a father may project those feelings onto the analyst, which helps the patient to understand those actions and emotions, and thereby resolving those conflicts.
Dream interpretation is a major part of psychoanalysis, because Freud believed that dreams were the unconscious’s way of ‘dealing’ with certain conflicts or emotional distresses. For instance a patient who has a recurring nightmare of fighting with a sibling, someone who in reality they like, may have repressed feelings of jealousy concerning that brother or sister, the dream is the unconscious’s way of trying to resolve the repressed feelings, and in analysis the patient should come to realise and resolve those unconscious emotions.
The resolution of those repressed feelings are the key to psychoanalysis, to “make the unconscious, conscious” is how Freud described the process, and through resolution the neurotic symptoms will disappear. Whereas Freud viewed neurotic disorders to be as a result of unconscious mental processes, the behaviourist school of psychology, and therapists related to that, view neurosis to be as a result of conditioning processes.
Wolpe developed behaviour therapy through his questioning of psychoanalysis and in particular the reasons why it had not been used, or accepted, in the Soviet Union, this led directly to Ivan Pavlov who had developed theories on conditioning, and to Hull’s (1943) learning theories. Wolpe’s own experiments led him to develop the principles of behaviour therapy which takes the view that, through classical conditioning, behaviours are learnt via the mechanisms of stimulus and response, and fear and anxiety are as a result of those reactions to conditioning.
According to Eysenck (1960) if you “get rid of the symptoms…… you have eliminated the neurosis”, the symptoms are eliminated through a process of reverse conditioning, to take the example mentioned previously of the person with a phobia for snakes, where the psychoanalyst would ‘talk’ the person through the phobia and attempt to uncover the ‘hidden’ conflicts on which the phobia is based, the behaviour therapist would use methods such as flooding or desensitising.
Exposing the client to the object of the fear to condition them to accept the anxiety causing object, until it had no fear for them. An opposing, idiographic approach to behaviour therapy is that of Behavioural psychotherapy which takes the view that, since current environmental relations are also affecting behaviours, these should be isolated and analysed, in order to change behaviour.
This is done by describing the observable behaviour (operationalizing) in order to draw the patients attention to the underlying motivations of maladaptive behaviours. For instance, if a child only receives ‘attention’ from it’s parents when it is running around the house screaming, it is being conditioned by the ‘reward’ of attention to behave in a certain way, its behaviour is being reinforced.
This child may develop into an adult who finds it difficult to form positive and healthy relationships, because others find his/her behaviour unacceptable, a behavioural psychotherapist would attempt to guide the client to a realisation of why these behaviours have been adopted and how they are manifesting themselves in the present. A Behaviour therapist may offer a therapy which involves positive reinforcements for opposite behaviours, thereby reconditioning the client with a new set of behaviours, with no regard to the emotions or feelings attached to those behaviours.
Wolpe describes the manifestation of neurotic symptoms as a “persistent unadaptive habit that has been acquire by learning in an anxiety-generating situation (or a succession of situations) and in which anxiety is usually the central component” so behaviour therapy is attempting to eliminate the anxiety response and disassociate it from those situations. The methods used are directly related to the extinction theory observed by Pavlov, systematic desensitisation involves a step-by-step breaking-down of the conditioned responses.
Used in conjunction with relaxation techniques it is extremely successful in the treatment of phobias, when the patient is exposed to the cause of the anxiety in increasingly larger ‘doses’, for instance in the treatment of Agoraphobiacs (usually manifesting itself as a fear of leaving the home) the patient might be required in session one to stand on the doorstep for a few minutes, the next session might last a little longer or the patient might be asked to walk to the front gate, over a period of session’s as the patient becomes used to the feeling of anxiety and learns to cope and relax, the therapy should eliminate the fear responses.
With flooding the patient is overloaded with anxiety, the purpose of which is to demonstrate to the patient that the fear has no rational basis, once the patient realises that he/she can leave the house and cope, albeit after a period of very high anxiety, the patients fear response should become extinct.
Wolpe himself used this method on a teenage girl who had a fear of cars, forcing her into the back of a car, he drove her around for four hours, after an initial period of hysteria she began to relax and by the end of the journey her fear had disappeared, today these methods are only used with the patients consent and co-operation and Wolpe’s actions would be seen as totally unethical and unacceptable. Wolpe claimed that Behaviour therapy had a 90% success rate, a claim that has much to dispute it.
However, whilst he made this claim, Wolpe acknowledged that there are differences between the types of clients who present themselves to therapists working from this approach and the types of ‘disorders’ from which they suffer. For instance many people who undergo Behaviour therapy are suffering from mild phobias or disorders, as opposed to the, sometimes, extremely disabling mental disorders which affect those who may seek other types of counselling or psychotherapy. Much research has been conducted recently on how successful therapies are in treating mental disorders, concentrating on two main approaches, outcome and process.
Outcome research looks at quantitative data and attempt to discover in those terms, how many people are judged to have ‘recovered’ after therapy. In 1952 Eysenck conducted a large scale study of this kind, by compiling results from a number of previous studies and evaluating those results. Looking at four categories (cured/much improved, improved, slightly improved and not improved/died/left treatment) he looked at psycho analysis and eclectic therapies (therapies which used a number of different approaches) and found that psychoanalysis had a 44% ‘success’ rate compared with the 64% of eclectic therapies.
Eysenck also includes a figure for those who were treated custodially (i. e. in a mental hospital or other) and those treated by their GP and threat for those was 72%. However, although it might appear that being treated by ones own GP or in a hospital or unit of some kind is a better option certain qualifications must be made. In psychoanalysis it is regarded that if a client stops or leaves treatment they may be regarded as not being improved and Eysencks figures include this qualification.
It may of course be that a patient left therapy because they felt improved and if this is the case and those patients who stopped therapy are not included in the ‘not improved’ category the figure for psychoanalysis rises to 66%. This immediately highlights one of the major problems with any kind of evaluation, that of judging improvement, a therapists subjective opinion may disagree with a patients subjective opinion, and later research has looked at that inadequacy and attempted to gain an objective opinion from an outside observer.
However, any judgement by an outside observer will also be subjective and if the judgement conflicts with that of the therapists and/or the patient, who’s opinion should the researcher include in any data. Another method of comparing therapies can be to use a control group, who have similar problems and don’t receive therapy, this method enables the researcher to compare the ‘spontaneous recovery’ rate with the rate for recovery after or during therapy. Sloane et al (1975) used this method and looked at the effectiveness of ‘time-limited’ therapy, i. . therapy that (in this case) lasted 14 sessions, over four months. Sloane compared psychodynamic therapies with behavioural therapies and allocate every third applicant to a waiting list, these were offered a telephone help-line and support from a GP. An initial assessment was made of all clients and after the four months a follow-up assessment was made to judge if any improvement had been made. The results show that improvement was made in all three groups, although those who had therapy improved at a slightly higher rate.
Lambert (1989) points out in his critique of the Sloane study that only three therapists were used in each group and there is further evidence to show that different therapists, even with the same field, may have different rates of success, this may be because therapy is a very personal process, and as Freud would argue, the relationship between therapist and patient is necessarily deep and complex, it is, therefore, debatable whether this kind of research could ever really discover whether therapy is effective.
Researchers, bearing these problems in mind, turned to Process research, which looks at the process of therapy, which is a qualitative approach, looking at what happens during therapy. This is a relatively new field, and it could be argued that as far as how successful this approach is ‘the jury isn’t in yet’. Pinsof & Greenberg (1986) emphasise three aspects of process research, which are activity over time, directional change, and movement towards completion. In order to truly observe the processes involved in psychotherapy it is necessary for a researcher to have access to that therapy session, in the form of direct observation (i. . a one-way mirror) or through tape recordings or video recordings, this raises ethical issues about client confidentiality and privacy. Whereas with psychoanalysis it may be possible to observe the process of change in a patient it is, probably, not entirely necessary where behaviour therapy is concerned, a behaviour therapist in the tradition of Wolpe is less interested in the internal motivations of the client to change and more concerned with the outcome, therefore this might be a more appropriate method to look at it’s effectiveness.
Wilcoxin & Kazdin (1976) in a study on the effectiveness of systematic desensitisation appeared to find evidence that it was not the process during therapy that was important but the exposure to the object of fear. This means that relaxation or graded exposure, according to the researchers, is not necessary for therapeutic benefit, and this may be why flooding can be just as effective as systematic desensitisation.
However process research combined with outcome research is probably an appropriate way to view any ‘talking cures’ because both the processes that occur during therapy and the end result must be important, as must the progress of the patient in periods of time after therapy, i. e. a year or ten years later, for it would be pointless to regard therapy as successful and effective if, a number of years after therapy had ceased, the patient deteriorates and becomes ill again.
It would also seem a nonsense to regard the recovery of a patient as a matter of a therapists opinion and with this in mind many researchers use self-report, and patient evaluation as the basis for their research. In the light of the previous research and evidence in their findings it could be argued that therapy, of any kind, is almost impossible to evaluate, since those processes involved are not available to the researcher, namely those thoughts, feelings and emotions which are occurring outside the field of observation, within the patients personality.